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Pain management with medicinal cannabis

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Home
Medicinal Cannabis
- Videos
Conditions
Pricing
About Us
- Testimonials
Blog
Contact Us

Home
Medicinal Cannabis
- Videos
Conditions
Pricing
About Us
- Testimonials
Blog
Contact Us

Home
Medicinal Cannabis
- Videos
Conditions
Pricing
About Us
- Testimonials
Blog
Contact Us

Registration Form

Please complete this form to register with Cannabis Doctor.

Name *

Gender *

Male
Female

Are you pregnant? *

Yes
No

Are you breast feeding? *

Yes
No

Do you have personally or 1st degree family history of Schizophrenia or Psychosis *

Yes
No

Are you currently using Marijuana (except prescribed medicinal marijuana) or other recreational drugs? *

Yes
No

Date of birth *

Address *

Mobile *

Email *

Do you suffer from one or more of these conditions? *

Chronic pain
Fibromyalgia
Migraine
Anxiety
Epilepsy
Nausea and vomiting from Chemotheraphy
Other condition

Other conditions you are suffering from? *

Do you have *

Heart condition
Diabetes
None of above

Any other medical or mental health conditions? *

Do you *

Smoke
Drink alcohol
Take Marijuana or other recreational drugs
None of above

Have you ever tried medicinal cannabis and in what form and for what reason *

What medications are you currently taking? *

Are you allergic to any anything / medications / other? *

What is your expectation from taking medicinal cannabis eg Relieve pain / Manage anxiety, etc *

By submitting this form, I declare that all information I have provided is true and I give informed consent with an appointment with the Doctor, who will advise me and prescribe Medicinal Marijuana as appropriate to manage my condition. I acknowledge that the Doctor is not obliged to prescribe if not appropriate *

Yes

Cannabis Doctor is the ideal solution provider to assess, manage and treat your health related conditions with Medical marijuana.

Contact Us

0800 362 226

info@cannabisdoctor.nz

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Phone

Our team is away on holiday. Our phone 0800 326 226 may be unattended during this time. Please kindly email us on info@cannabisdoctor.nz

Alternatively, you can leave a message through our contact us section.